Failure to Rescue
Prior to my being hired, a patient died from a pulmonary embolism after undergoing an orthopaedic surgical procedure to correct a fractured hip. The patient was young (in his 50Ã¢Â€Â™s) and although his respiratory decline and mental deterioration were noted, the staff failed to promptly recognize that a life threatening problem existed.
This incident was one of the driving forces in creating a Nurse Practitioner team to work with the Ortho-Trauma patients at our institution. The Ortho-Trauma med-surg floor consists of 45 beds (13 private) and has undergone vast staff turn over and internal change over the past 5 years. The total joint program (elective hip and knee replacements) moved to another facility transitioning this unit into one focusing on the growing number of ortho-trauma patients.
During my interview I asked one of the attending physicians why they specifically wanted Nurse Practitioners and not more Physician Assistants.
His blunt, unhesitating response? Ã¢Â€ÂœI want nursing intuition.Ã¢Â€Â
Fast forward to Memorial Day of this year. Staff was surprised when they saw me show up at 0600 on a day they assumed I had off. I knew that last Memorial Day, the resident on call had 39 consults (busy is 20). I also knew that the weather was going to be good. Imagine my lack of surprise when my patient census list hit 49 patients, more than 2/3rds new to me.
Mid point of the shift found me in the allied health room reviewing patient hospital course and status with one of the RNs. A family member of a fresh post-op patient approached the desk to relay their concern for the patient who, Ã¢Â€ÂœwasnÃ¢Â€Â™t acting or breathing right.Ã¢Â€Â The patientÃ¢Â€Â™s nurse, who was also in the room, said that she would be there in a minute, but looked unconcerned and unhurried. I quietly asked the nurse what the story was and was told the following:
Ã¢Â€Â¢ He had just been admitted from the PACU
Ã¢Â€Â¢ Diagnosis: BKA s/p unsalvageable ankle fracture/crush injury 5 days prior
Ã¢Â€Â¢ It was unknown to her how much pain medication had been given in the PACU
Ã¢Â€Â¢ He was in the SICU immediately prior to surgery
This was relayed to me while the RN sat in the chair making no move to go to the patient. I calmly asked for the chart, which was still with the patient. I suggested that we go down to the room and check him out together. On observation, he was pale, diaphoretic, lethargic, having periods of apnea (breathing only when stimulated), Alert and oriented x 0 and the family, to include the father, was in tears.
What would have happened had I not been eavesdropping?
In 2003, Sean Clarke and Linda Aiken from the Center for Health Outcomes and Policy Research at the University of Pennsylvania published the article, Ã¢Â€ÂœFailure to Rescue.Ã¢Â€Â (American Journal of Nursing, Jan. 2003, 103 (1), p. 42-47). They define Ã¢Â€Â˜failure to rescueÃ¢Â€Â™ as Ã¢Â€ÂœÃ¢Â€Â¦cliniciansÃ¢Â€Â™ inability to save a hospitalized patientÃ¢Â€Â™s life when he experiences a complication (a condition not present of admission).Ã¢Â€Â
The idea of failure to rescue is based on the idea that many deaths which occur in hospitals are preventable. Common sense, AND RESEARCH, tells us that the nurse is the most important factor in the rescue success of these patients.
Kathy McCauley, President of the AACN, states that, Ã¢Â€ÂœWe [nurses] are the eyes, ears and hands of the health system every minute of every day.Ã¢Â€Â
How can I, as a very green NP, convince the staff that without their diligence, patients will die?
Ã¢Â€ÂœNurses are not taught to do a primary and secondary surveyÃ¢Â€Â¦a primary survey evaluates the patient’s airway, breathing, and circulation. Sound familiar? A secondary survey is just that, a second look at the patient from head to toe after you make sure that the ABC’s have been addressed. Nurses do the same thing but it’s not taught this way and is not broken down this way in nursing school (although I think it should be). We waste more time in touchy-feely crap we could have spent in learning patient pathophysiology. It’s criminal. As a nurse practitioner you will have to alter your philosophy of patient care to include the mental steps of deciding on a medical plan of care.Ã¢Â€Â
(Thanks to The NP Blog for the link)
Besides not processing that the patient needed to be urgently assessed when the family voiced their concern, the nurse didnÃ¢Â€Â™t think to IMMEDIATELY start the patient on oxygen when the pulse ox read 58%. Unfortunately, this is not the first time I have run into this lack of response to low pulse ox readings.
What happened to nursing intuition? Where is the critical thinking? Has it truly been lost in all of the Ã¢Â€Â˜touchy-feely crapÃ¢Â€Â™ that Azygos mentioned?
In a recent conversation an attending physician expressed his nostalgia for the good olÃ¢Â€Â™ days when the nurses took control, made decisions, and were proactive in patient care. He missed doing rounds and having the nurse tell him the over night events and point to where he needed to sign for the orders she wrote in his name. The confidence in the nursing staff is ceasing to exist.
How do I fight this tide of chaos and return the nurses to understanding that they are patient advocates?
I believe that this unit is at a very critical point. Trauma season has begun. Nurse-Patient ratios are getting better, but are still at almost dangerous levels. In leading by example, I know I need to follow the advice of Clarke and Aiken, teaching or reteaching nurses the following:
Ã¢Â€Â¢ Frequent Assessments
Ã¢Â€Â¢ Acting on Patient Cues
Ã¢Â€Â¢ Recognize complications
Ã¢Â€Â¢ Institute measures based on the ABCs
Ã¢Â€Â¢ Activate a team response (NP, physician, respiratory therapist, etc.)
Ã¢Â€Â¢ Anticipate equipment/information needs
Ã¢Â€Â¢ Administer life saving measures
It is my hope that this post is the beginning of a dialog. I am searching for answers to a seemingly insurmountable, and life threatening, set of circumstances. Where should I go now?